This internal website is for City of San Rafael employees. The public website is www.cityofsanrafael.org.

Worker’s Compensation Forms

Workers’ Compensation provides eligible workers who are either injured or who become ill during the course of employment with medical coverage and, if applicable, disability coverage. The program is legislated by State law. The City’s self-funded Workers’ Compensation program is administered by LWP Claim Solutions, Inc. (LWP).

  1. Worker’s Comp Claim Form (Turn in to HR -ASAP)
  2. Employers Report of Occupational Injury or Illness – Form 5020 (Turn in to HR -ASAP)

RU-91 forms

LWP Claims Solution, Inc.
PO Box 349016
Sacramento, CA 95834-9016
T: (800) 565-5694
Fax: (408) 725-0395
Email: Info@lwpclaims.com

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